Why this summer is make-or-break for star ratings

Published: Mon, 08/18/25

Updated: Mon, 08/18/25

Link to all things medical coding & billing

Why this summer is make-or-break for star ratings

While plans are still grappling with last year’s significant changes to The Center for Medicare and Medicaid Services (CMS) 2025 Star Ratings, more change is on the way. The new administration and Dr. Mehmet Oz, as leader of the CMS, have pledged stricter scrutiny of insurers and have indicated that more measures are on the horizon. For Medicare...

Wound Care: Medicare Audits & The Skin Substitute Surge

Federal contractors – Recovery Audit Contractors (RACs) and Unified Program Integrity Contractors (UPICs) – have increasingly targeted wound care claims, particularly involving expensive skin substitutes billed under Medicare Part B. In 2023 alone, over $1.6 billion was spent on these products, prompting heightened audit activity from Qlarant...

Understanding the 2025 Telemedicine E&M Codes

The American Medical Association (AMA) introduced 17 new telemedicine evaluation and management (E&M) codes this year. Here’s the breakdown of these new codes: CPT® code range 98000-98007 are reported for synchronous audio-video encounters, and CPT code range 98008-98015 are reported for synchronous audio-only encounters...

5 Jobs AI Will Practically Own By 2026

The robots aren’t coming. They’re already here. Last week, I had a chat with my accountant, a 45-year veteran who said his son's job just got replaced by ChatGPT. I won’t name the firm in London. Not downsized. Not restructured. Replaced. While everyone’s debating whether AI will take over the world, it’s quietly taking over paychecks. Goldman...

CMS Proposes Elimination of Inpatient-Only List

The Centers for Medicare & Medicaid Services (CMS) issued its Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for the 2026 fiscal year this week, and in doing so said that the Inpatient-Only List (IPO) should be phased out over the course of the next three years. The move will reportedly begin with the...

DRG Downgrades by Commercial Payers: Documentation Defense Tactics

In the current climate of cost containment, commercial payers are increasingly downgrading MS-DRGs after claims are submitted, not disputing the need for inpatient care, but questioning the clinical support for CCs (complications or comorbidities) and MCCs (major complications or comorbidities). These downgrades reduce reimbursement, often occur...

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